1. ANTI-COAGULATION

2. ENOXAPARIN DOSING Obesity (BMI >= 40 kg/m2) – may increase prophylactic dose by 30% such as in bariatric surgery Abdominal Surgery …. 40 mg q day with initial dose given 2 hrs prior to surgery & continue 7-10 days Hip Replacement …… 30 mg q 12 hrs or 40 mg q day, with initial dose 12-24 hrs after surgery, x 10 days or until risk is less or pt on warfarin for 35 days. Knee replacement ….. 30 mg q 12 hr or 40 mg q day, with initial dose 12-24 after surgery for 10 days (some recommend 35 days) Mobility Restricted …. Either 30mg (crcl 30) q day…within 24 hrs after surgery, hx dvt, high risk DVT or Pulmonary embolism = 1mg/kg q 12hr or 1.6 mg/kg q day Pregnant women- 1mg/kg/dose q 12 hr. Stop >=24 hrs prior to induction of labor. Continue x >=6wks postpartum PCI – if pt has gotten enoxaparin < 8hrs ago, no additional enoxaparin needed. PCI- if pt has gotten enoxaparin 8-12 hrs previous.. Give single dose of 0.3 mg/kg x 1 PCI- if pt has gotten enoxaparin > 12 hrs previous. Give full dose. ST- elevation MI (STEMI) – 30mg iv bolus + 1mg/kg subq every 12 hrs. (max 100mg for first 2 doses). Additionally All pts should receive aspirin indefinitely and clopidogrel. ATRIAL FIB- use the 1mg/kg therapeutic dose.

3. ENOXAPARIN Mechanical heart valve (aortic or mitral) to bridge therapy- 1 mg/kg q 12 hrs Unstable angina or non=ST elevation (NSTEMI) – 1mg/kg q 12hrs w asa for at Least 2 days or up to 8 days) Precautions Epidural Catheters….. Stop Lovenox 12 hrs prior to insertion/extraction, may Restart it 1 hour after procedure Procedures…………… Stop heparin 12 hours prior to procedure Stop lovenox 12-24 hours prior to procedure Stop warfarin 5 days prior to procedure or INR < 1.7

4. CHAD (2) SCORING If stroke is due to atrial fib.. Then anticoagulant per AF CHAD guidelines

5. ATRIAL FIBRILLATION CHAD2 = CHF=1 HTN= 1 Age>=75 =1 DM=1 Stroke or TIA= 2 Chad 0= no therapy or aspirin 81-325 mg / day CHAD1= OAC or aspirin 81-325 mg/day (ACCP= prefers dabigatran over VKA) CHAD2= OAC (for high risk pts not considered candidates for OAC= aspirin+Clopido)

6. ACTIVASE - EXCLUSIONS Surgery within past 3 months HTN > 160/90 Outside 3-4.5 hr therapeutic window On an anticoagulant Age > 80 YO HX Stroke & DM.

7. CARDIO-CONVERSION IN AF Thrombi present plus cardioversion = 91% stroke rate. AF for greater than 48 hours = 15% rate of atrial thrombus AF for greater than 72 hours= 30% rate of thrombus. Anticoagulant 3-4 weeks prior to conversion Anticoagulant for at least 4 weeks after conversion.

8. STROKE- TREATMENT WITH ACTIVASE Within 4.5 hours of symptom onset Dose 0.9 mg/kg IV, 90mg max, then 10% of it as bolus, rest given over 1 hour Improvement of symptoms Intracranial or subarachnoid bleed Other active bleed, intracranial surgery with past 3 months Major surgery in past 2 weeks, age > 80 GI or UT bleed in past 3 weeks, previous stroke combined with DM BP >185/110 or aggressive tx to lower bp Pregnancy, seizure, neoplasm, taking nother anticoagulant, Plts < 100k

9. STROKE-SECONDARY PREVENTION American Stroke Association recommends aspirin-dipyridamole or aspirin, or clopidogrel. (initiate aspirin 160-325 mg after initial dose with 50-100mg q day within 48 hrs of stroke Use warfarin if Afib is associate with prosthetic heart valves.

10. STEMI (MI) TREATMENT (M) orphine 2-4 mg q 5-15 min prn (O) oxygen---- if O2 sats < 90% (N) itroglycerin (A) spirin chew and swallow 62-325mg Beta-blocker-start within 24 hrs Ace-inhibitor- start within 24 hrs Aldosterone antagonist Statin, nitrates, ccb

11. NSTEMI - TREATMENT Antiplatelet plus P2Y12 plus ASA PCI- balloon, stent implantation